Question

Please review the operative reports given and audit the coding. Please write if the codes are correct or if a different code should be used. Also if a modifier is missing please add it to the code.

If everything is correct please write down that you agree with the codes.

1. Case #3

Clinical History/Indications: Patient with Hepatitis C

Preliminary ultrasound was performed and a suitable biopsy sire localize over the right lobe of the liver. Conscious sedation was obtained with intravenous Versed and Fentanyl. The skin was prepped and draped in the usual fashion. Local anesthesia was obtained. Using sonographic guidance a core biopsy of the right lobe of the liver was performed using a 16 gauge Monopty needle.

Pathology report: moderate cirrhosis associated with chronic hepatitis C.

47100 wedge   77002

2. Case #4

Clinical History/ Indications: hemoptysis, rule out endo-bronchial pathology and etiology

Procedure: After informed consent, the patient was brought to the endoscopy room and he was prepared for bronchoscopy. The patient was given 1 mg of Versed and 25 mg of Fentanyl preoperatively. The video bronchoscope was passed from the right nostril into the nasopharynx and larynx where the vocal cords were identified. The vocal cords appeared normal. The vocal cords were anesthetized with 2% lidocaine and the bronchoscope was advanced into the trachea. The trachea appeared normal. No endobronchial lesions were noted. The bronchoscope was advanced to the carina, the right and left main stems were identified. Then the bronchoscope was advanced to the right upper lobe, the right middle and the right lower lobe. The mucous was irritated and had some patchy appearance. Three biopsies were taken from the right lower lobe and two form the middle right lobe. A nodular density was noted in the left lower lobe bronchus. Two trans-bronchial lung biopsies were taken from this area with fluoroscopic guidance. No bleeding was noted. Bronchioalveolar lavage was done on the left upper lobe as severe irritation and mucus was found in this area. The patient tolerated the procedure well.

Postoperative diagnosis: bronchitis, left lower lobe mass suspicious for malignancy. Biopsy results are pending.

31622 31624 31625x5 31628 31632

3. Case #5:

Indications: Proximal left ureteral calculi

Operation: Cystoscopy and placement of a left double J ureteral stent

Extracorporeal shock wave lithotripsy of left proximal calculi

Extracorporeal shock wave lithotripsy of left renal calculi

Procedure: Under general anesthesia the patient was prepped and draped. A cystoscopc examination revealed both ureteral orifices to be normal, the bladder was unremarkable. A #6 French double J stent was engaged on a guide wire and was advanced all the way up to the collecting system under direct fluoroscopy monitoring, the guide wire was removed and the stent position was verified under fluoroscopy. The proximal left ureteral stone was in position and lying outside the double J stent. The patient was then taken to the lithotripsy suite. The proximal ureteral stone was placed in the blasting path both on camera one and on camera two and a total of 1,300 shocks were given to this stone until adequate fragmentation was accomplished. A second stone was identified in the lower pole calyx of the kidney and the a total of 210 shocks were given and then remaining shocks of 2,000 were necessary to fragment this kidney stone. The procedure was successful and the patient was taken to the recovery room in satisfactory condition

Codes 52332 50590

4. Case #6

Indications: 50 year old male with carcinoma of the bladder

Operation: Placement of a Port-A-Catheter

Procedure: the patient was taken to the operating room and placed on the operating table in supine position. With the right neck and chest prepped and drapped 1% Xylocaine was injected and percutaneous catheterization of the right subclavian vein was performed. A guide wire was advanced and placed into the superior cava vein with its location verified by fluoroscopy. Next, a supra-pectoral pouch was created below this needle insertion site. The port was placed into the pocket sewn into place using 2-0 silk suture with the catheter tunneled in to the needle insertion site and cut to an appropriate length. The system was filled with heparinized saline solution. Then under fluoroscopic guidance, the introducer was placed over the guide wire into the superior cava vein. The catheter was placed through the introducer system, with good antegrade and retrograde flow through the system. The wound was irrigated and closed using a 3-0 Dexon and 4-0 Maxon in a running fashion. Sterile dressings were applied.

36571

Answer 1

1 Wrong. .77002 is fluroscopic guidance for needle placement.76998 is ultrasound guidane for needle placement,47100 biopsy of liver wedge is used when no other abdominal procedure has been performed.Therefore 47100 wedge 77002 is the answer.

2 31625 is the code for performing bronchoscopy along with biopsy.31622 is bronchoscopy,rigid or flexible including fluroscopic guidance when performed and does not include a biopsy. it is used for diagnostic portion.the procedure is first performed to examine the inside of the patients lungs.if a problem such as a lesion is located,the physician may continue the procedureby performing a surgicsl intervention such as biopsy..Because the diagnostic part is inherent to the surgical portion.But cpt code 31628 clearly shows bronchoscopy ,rigid or flexibe ,including fluroscopic guidance,when performed,with transbronchial lung bopsy single lobe.therefore 31628.

3 Agree 52332 iscystoscopy with insertion of indwelling urethral stent .50590 i lithotripsy with extracorporeal shock wave therapy.When you are doing an ESWL 50590 you can also bill for the placement of a stent ,the 52332.

4 agree with the code 36571 .Fluroscopic guidance for CVA device placement ,replacement or removal ie vascular access.